´A Learning Route on Innovative Livestock Marketing from Northern to Eastern Africa´
27 February – 9 March, 2012 - Kenya
INSCRIPTION FORM
LEARNING ROUTE
´A Learning Route on Innovative Livestock Marketing
from Northern to Eastern Africa´
27th February – 9th March, 2012 - Kenya
PERSONAL INFORMATION
Surname
Name
Other names
Sex
Female
Birthdate
Male
(day/month/year)
Country of residence
City
Physical address
1)
Email
2)
Country code
Area code
Number
Telephone
Fax
Cellphone
Identification document
Passport number
Emission date
Expiry date
National ID number
Emission date
Expiry date
Languages
1)
2)
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´A Learning Route on Innovative Livestock Marketing from Northern to Eastern Africa´
27 February – 9 March, 2012 - Kenya
Education (Please mark with and X the corresponding answer)
Level
Completed
Uncompleted
Primary school
Secondary school
Technician
University
Others
Access and use of the internet
Do you dispose of a computer?
Yes
No
Do you have access to
internet?
Yes
No
Where?
Where?
Home
Work
Public cabins
Other
(Please state which one)
Home
Work
Public cabins
Other
(Please state which one)
How often do you surf in the web?
What kind of internet
connection do you have?
Phone connection
Broadband
Other
(Please state which one)
Are you part of any social
networks?
Daily
3 times a week
Once a week
Every 15 days
Once a month
Every 2 months or so
Facebook
Twitter
MySpace
Other
Please state your username
Profession or
position
Technical or
professional
specialty
POSITION THAT YOU CURRENTLY HAVE IN THE ORGANIZATION, COMPANY OR
INSTITUTION: (Name of the position)
Please select the choice that describes better your position:
1. Director of an institution, programme or project
2. Functionary, operator or member of technical staff of an
institution, programme or project
3. Director of a rural organization (association, cooperative,
company)
4. Member of a rural organization
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´A Learning Route on Innovative Livestock Marketing from Northern to Eastern Africa´
27 February – 9 March, 2012 - Kenya
5. Independent professional, technician or local talent
6. Other (please specify)
7. Entrepreneur
CAN YOU MENTION THE REASONS WHY YOU WISH TO PARTICIPATE TO THIS LEARNING
ROUTE?
CAN YOU DESCRIBE WHAT ROLE WILL YOU BE PLAYING IN THE IMPLEMENTATION OF
INNOVATIONS AND IN IMPROVING PROJECT PERFORMANCE?
DESCRIBE THE FUNCTIONS OR TASKS THAT YOU ARE IN CHARGE OF WITHIN THE
ORGANIZATION, PROGRAMME OR PROJECT IN WHICH YOU CAN APPLY THE LEARNING
FROM THE LEARNING ROUTE
NAME OF THE ORGANIZATION, INSTITUTION OR COMPANY OF THE APPLICANT
TYPE OF ORGANIZATION, COMPANY OR INSTITUTION (Please mark the most appropriate
choice)
1. Civil society organization
1.1 Economic organization (cooperatives, associations, etc)
1.2 Technical support organization or NGO
1.3 Second level organization (network, federation, other)
1.4. Academic institution, university, study center
2. Rural development project
3. Public entity
4. Local, regional government
5. International organization
6. Company
6. Other (please specify what kind)
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´A Learning Route on Innovative Livestock Marketing from Northern to Eastern Africa´
27 February – 9 March, 2012 - Kenya
IS YOUR ORGANIZATION LINKED TO IFAD?
YES ___
NO___
How?
YES __ NO___
IS IT LEGALLY CONSTITUTED?
What is its legal figure?
From when?
MAIN ACTIVITIES OF THE INSTITUTION, COMPANY OR ORGANIZATION?
COVERAGE OF THE ACTIVITIES OF THE ORGANIZATION, COMPANY OR INSTITUTION
International
National
Regional
Local
NETWORKS
Does your organization gather other institutions, organizations or
collective groups?
Which ones?
YES ___ NO __
Does it belong to other networks, associations, alliances or
articulations (local, regional or national)?
Which ones?
YES ___ NO__
NUMBER OF MEMBERS OF THE ORGANIZATION, COMPANY OR
INSTITUTION
Nº of women
Nº of men
Total Nº
(Please classify them according to their age)
Nº of people under 18 years old
Nº of people between 18 and 35 years old
Nº of people between 36 and 59 years old
Nº of people of 60 years old and above
Total Nº
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´A Learning Route on Innovative Livestock Marketing from Northern to Eastern Africa´
27 February – 9 March, 2012 - Kenya
CONTACT DATA FROM THE ORGANIZATION, COMPANY OR INSTITUTION
COUNTRY
CITY
PHYSICAL ADDRESS
NAME OF THE MAIN
DIRECTOR
EMAIL ADDRESS
TELEPHONE NUMBER
1)
2)
Country
code
Area code
Number
FAX
Mobile PHONE
THANK YOU VERY MUCH FOR FILLING THE INSCRIPTION FORM!
Please send it back to
dpuyo@procasur.org and vsauve@procasur.org
We will contact you very soon!
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